MDM - Otitis Externa

[##]-year-old [male/female] with [ear pain/drainage] with history and exam consistent with likely otitis externa of the [right/left/bilateral ear(s)].

Initial considerations in this patient included otitis externa and malignant otitis externa, auricular hematoma, acute otitis media, mastoiditis, ear foreign body, tympanic membrane rupture, and other upper respiratory infections (URI) among others.

Patient presented with complaint of [right/left]-sided otalgia, and was noted to have associated erythema, swelling, and [otorrhea/debris] in the external auditory canal consistent with otitis externa.  Patient noted to have no evidence of swelling, erythema or tenderness to the [right/left] mastoid process or protrusion of the ear to suggest mastoiditis.  Patient noted to have [no] evidence of fever or other systemic infectious symptoms suggestive of malignant otitis externa in patient [with/without] risk factors [including diabetes/immunocompromise].  [There was no indication for wick placement at this time/A wick was placed prior to discharge and infiltrated with antibiotics]. 

Patient noted to have improvement in pain with [NSAIDs] prior to discharge.  Prior to discharge, we discussed return precautions, specifically for worsening infection, treatment with [oral/otic] antibiotics [and wick with NSAIDs for pain], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.